How did heroin spread beyond big cities in America? What's the connection between heroin and America's opioid problem? Sam Quinones, author of Dreamland, talks with EconTalk host Russ Roberts about the explosion in heroin use and how one small Mexican town changed how heroin was produced and sold in America. That in turn became entangled with the growth in the use of pain-killers as recreational drugs. Drawing on the investigative reporting that culminated in his book, Quinones lays out the recent history and economics of the growth in heroin and pain-killer usage and the lost lives along the way.
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Readings and Links related to this podcast episode
Related Readings
HIDE READINGS
This week's guest:
Sam Quinones's Home page
Sam Quinones on Twitter.
This week's focus:
Dreamland: The True Tale of America's Opiate Epidemic, by Sam Quinones at Amazon.com.
Additional ideas and people mentioned in this podcast episode:
Maps: Where are Xalisco, Jalisco, and the San Fernando Valley?
Xalisco, town in State of Nayarit, Mexico. Map, TheNortherner.com.
Jalisco, State in Mexico. Map, Wikipedia.com.
San Fernando, California. Maps and info, Wikipedia.com. N.B. The Wikipedia maps about the city of San Fernando showing where the city and the San Fernando Valley are located within California are more informative than the maps provided by Wikipedia's entries for the San Fernando Valley.
Oxycodone. Source of Russ's quote: "In the United States, more than 12 million people use opioid drugs recreationally." Wikipedia. Also see Opioid. Wikipedia.
A few more readings and background resources:
Pharmaceuticals: Economics and Regulation, by Charles L. Hooper. Concise Encyclopedia of Economics.
The Valley of the Dolls, by Jacqueline Susann. Early (1966) novel describing widespread pill and barbiturate use by middle and upper class Americans. Wikipedia.
A few more EconTalk podcast episodes:
Chris Arnade on the Mexican Crisis, TARP, and American Poverty. EconTalk. October 2016.Angus Deaton on Inequality, Trade, and the Robin Hood Principle. EconTalk. October 2016.
Marcia Angell on Big Pharma. EconTalk. November 2012.
Jonathan Skinner on Health Care Costs, Technology, and Rising Mortality. EconTalk. July 2016. Opiate addiction increases.
Okrent on Prohibition and His Book, Last Call. EconTalk. June 2010. Alcohol, prohibitive laws, and crime.
David Skarbek on Prison Gangs and the Social Order of the Underworld. EconTalk. March 2015. Gangs and return to street gangs after jail time.
Nathaniel Popper on Bitcoin and Digital Gold. EconTalk. June 2015. Online payments include paying for drugs.
Highlights
Time
Podcast Episode Highlights
HIDE HIGHLIGHTS
0:33
Intro. [Recording date: December 12, 2016.]
Russ Roberts: I want to remind listeners to go to EconTalk.org where you'll find a link in the upper left-hand corner to this year's annual survey of your favorite episodes.
00:47
Russ Roberts: Now for today's guest, author and journalist Sam Quinones. His latest book is Dreamland: The True Tale of America's Opiate Epidemic, which is our topic for today's conversation. Sam, welcome to EconTalk.
Sam Quinones: Great to be here, Russ. How're you doing?
Russ Roberts: Doing great, especially after reading your book--more or less. Dreamland is one of the best nonfiction books I have read in a long, long time.
Sam Quinones: Well, thank you.
Russ Roberts: I couldn't put it down. It was deeply disturbing in many ways, but incredibly illuminating about an issue that we have touched on a number of times here on the program, which is the opioid epidemic. But I want to start at the beginning, which is actually heroin. So, I want to start with the revolution in the production and distribution of heroin out of Mexico that you describe. And I want to start with the business model of what you call the Xalisco Boys (The "x" is pronounced like a guttural "h" or "ch", or like the Spanish "j": ha-lis'-co or ja-lis'-co). Xalisco being a small town in the Province of Mexico on the Pacific Coast, Nayarit. And it's spelled with an 'X': X-a-l-i-s-c-o.
Sam Quinones: Right. Not to be confused with the state of Jalisco, which is a very, very large state with Guadalajara as its capital.
Russ Roberts: Talk about what came out of Xalisco.
Sam Quinones: Right. These guys back in the early 1980s, families from this town, a town of about 20,000 people, landed and had then migrated to the San Fernando Valley of Southern California--Canoga Park, [?] area. A few of these families had figured out how to cook black tar heroin from the opium goo that grows in opium poppies. Opium poppies, you should know, grow very nicely and have about a century in the mounts of the Northwest of Mexico. And so, Nayarit is a state right on the Pacific Coast of Mexico, northwest. And so they had access to that. They began to learn how to cook the goo into what's called black tar heroin. Black tar is a kind of a sticky, gooey, semi-processed form of heroin. It's like a tootsie-roll kind of--every bit heroin just like white powder is. It's just not as processed and filtered and so on. And they began to sell this heroin in parks in the San Fernando Valley. A few of these families. Not very many. They would chip off little pieces; the addicts would come up and buy it from them. But in time, a couple of things happened. One was, the cops began to get wise to them. They got wise to them because more and more families from the town began to see this is as a viable business and began to get involved in it. That saturated the market. Now, these guys were different, though. Most times, you find in the underworld, people develop or grab market shares at the barrel of a gun. Al Capone started that, I think; and ever since, that's been the way people in that economy and market share. But these guys couldn't do that because they were all from the same town. They all knew each other. A lot of them were related. Sometimes they had gone to school together. Everybody knew where each others' mothers lived. So, they couldn't use that method. So they developed another method, and this really led to the system they developed, which was a form of selling heroin that resembled very much pizza delivery. So, you, the addict, would call a number. The operator, who was standing by to take your order, would then dispatch a driver. A driver would meet you at some predetermined place and sell you your heroin. And this got them out of the parks. The cops couldn't find them as easily. They also got access to a much larger market of heroin than they would have if they were just a stationary, in a park. And in time that process replicated itself. Even with cars: more and more guys come up from this town; more and more people get into the business. And so they have to move beyond even San Fernando Valley--they kind of saturate that, given the number of addicts that are in the area, they need to set the business model kind of saturates the market and they have to move to other cities. So, first there was Pomona, Ontario, which is about 30 miles east of LA (Los Angeles). I think they went to San Diego. Portland. Denver. They began to expand, very, very much like any capitalist small business or franchise would.
5:01
Russ Roberts: Now, talk about the ways they avoided detection. The first thing as an economist I noticed is they were very price conscious. Similar to the crack cocaine distribution, which was really an innovation in the magnitude, the size of the dose--what we're talking about here with the black tar is a tenth of a gram. And talk about how it's sold in balloons and how they use that to avoid detection.
Sam Quinones: Sure. They were not cartel-killers. They were not full-time drug traffickers. They were kind of guys who thought that they'd get some extra money. They were very aware of not wanting to go to prison. And so, the way they began to do it was--they also were retailers. Which is really rare in the Mexican drug-trafficking world. Most cartels, most drug-trafficking groups, they sell wholesale. These guys developed a retail--they realized that they had, that the profit was really in retail. And they began to put the dope in small, little balloons, tie them off; and they would put these ones in their mouths. So, you could--I've talked to guys who actually could put 20, 25 balloons in their mouths.
Russ Roberts: They are not inflated.
Sam Quinones: Not inflated. They are balloons that are just wrapped around, just to protect the dope in case the cops stopped them. And that's why they also carried a big jug of water. The cops stop them; they begin to swig on the water and they swallow the balloons down; and the cop doesn't find any dope on them. And that's one way they avoided detection. Very important in this was also: They never used guns. They, I think, learned or saw the Bloods and the Crips fighting it out for territory in those years for crack territory in Los Angeles. And heavy, heavy police attack on those folks. The Colombians were the same way--when they brought their dope into Miami they were very much given to shoot-outs and killing lots of people to kill one target. Of course, Al Capone, etc. These guys eschewed guns and completely understood--first of all, that they were not gunmen. But number two--an illegal immigrant. They were all here illegally in the country. An illegal immigrant with some dope would be deported. An illegal immigrant with some dope and a pistol would get 10 years in prison. This was very clear to them. So they really formed a system that relied far more on marketing, on customer service; on making sure that your dope was potent and that your customer got it on time. They were also, during these early years--the 1980s into the early 1990s, they were marketing, they were working during a time when the numbers of addicts--the demand was really small. And so they would go to one new town--say, Salt Lake or Portland--and a few of these crews would get there. They'd compete among each other. But in order to take customers from each other, they couldn't kill each other. So they had to out-market and do a better job of customer service, because they couldn't kill each other. So they became master marketers first, very early on. And this was also part of their way of developing a market. They developed personal relations; they'd give you 50 free balloons if you brought them 5 new customers. If you bought from me 6 days or a week I'd give you a free one on Sunday. These kinds of come-ons and gimmicks--
Russ Roberts: Free samples--
Sam Quinones: and that kind of thing were part of their business.
Russ Roberts: They gave away free samples. They'd go to a methadone clinic[?] and hang out[?]
Sam Quinones: They gave away free samples; they'd hang out in front of methadone clinics and give away free dope there. If they knew a guy well enough, he got out of jail, hadn't been using for 3 or 4 months they'd meet up at his house, give him free dope there, get him using again. There's a whole range of ways that they had of marketing and retaining market share that way instead of through the barrel of a gun.
Russ Roberts: So, as a hardcore free-market guy, there's a certain respect you have to have for that. But there's a really dark side to it, which is: Heroin addiction is not easy to get out of. In fact, you seem to suggest that you can't. Period.
Sam Quinones: Well, I'm not sure I would say you can't. I have known people who have. It's just a torment. It's a torment unlike any drug. It's a drug that deprives you of rational free will, I believe. I don't believe that when you are fully in addiction you have that free will, particularly, to heroin. So, these guys knew that. They knew that they were marketing a very potent drug. The other thing that I think they knew, too, was this: Heroin that used to come to the United States from the Far East--you know, the French Connection-type dope, and well, for most of the 20th century a lot of it came from Turkey or from Burma or from Vietnam or what have you--a lot of that dope had to change hands many times. By the time it got to the street it was pretty well diluted. Each time it changes hands, the guy, to make his money, he cuts it and he sells it for double. He makes 1 kilo into 2, or 4, and sells it for double and makes a lot of money that way. That's how you make your money. And so, for many, many years, the DEA (Drug Enforcement Administration) always found, when they did their tests on heroin that they would seize on the street, that the potency was 6 to maybe 15 to 18 percent. Something in that ballpark. These guys were making the heroin, their family members were making it; they were taking it themselves up through the border. Heroin is very, very easy to smuggle across because it's so condensable. And it would get to the United States in very, very potent form. They were not diluting it so much as the dope that would come from, say, Burma or someplace. It didn't have as far to go. Heroin is a commodity. It's not like a red wine or marijuana which has a lot of varietals. It's one thing. And the price really depends on how much you diluted it, and how far it had to travel. And in this case they didn't dilute it very much at all. And it had only maybe 2000 miles to travel instead of 12,000 miles, say. And so it got here much more potent and much cheaper, and that's what made their heroin very, very popular.
11:12
Russ Roberts: So, I have a couple of prices in the book: At one point you mentioned 25 doses for $100; 5 doses for $100--obviously it depended on the city and what level of competition there was.
Sam Quinones: Completely.
Russ Roberts: How many doses would a user who is in bad shape be using a day?
Sam Quinones: Usually about a gram to a gram and a half--so it could be 6 to 8. It depends. I would say 6 to 8 doses a day, perhaps, something like that. I found different people in different states, honestly, in my book, per person. So, that's the thing about heroin. That's what makes it a magnificent drug for drug traffickers. It really has no medicinal use, compared to other opiates from the same opium poppy: heroin is extraordinarily addictive and has more or less the same pain-killing qualities as others but it's far more addictive--because it takes you up and down: euphoria and then you crash very quickly. So, you need to be doing it 2, 3, 4, 5 times a day sometimes, and that's what leads to the addiction. That's what makes it very, very appealing to a street trafficker, because you've got a customer who's going to hit him up every day. There's no day--on Christmas, on Sundays, you're not saying, 'Maybe I won't use today.' No. You're using every day; you cannot not use this drug. And sometimes it's 3, 4, 5 times a day. And it also drives people to extraordinary ends: they are willing to sell anything; they are willing to find any client if they'll get them more free dope, they'll do it. A lot of these guys spread. The way they spread, the way they expanded to other cities was really with guides who were addicts. Addicts were their guides: they told them, 'Man, you bring this stuff to Reno, I know where the methadone clinic is there, and man, we could make a killing there. And you just give me my free dope; that's all I care about.'
Russ Roberts: Can a person hold down a job as a heroin user?
Sam Quinones: You can. And what I found was these guys changed that, though. I met guys, for example, addicts who would say, 'Back when it was hard to get, back when heroin was more difficult to get and was far more expensive and far more diluted, I was able to do more with my life. I was able to hold down a job, more or less; more or less handle family responsibilities and this kind of thing. Because it was hard to get: it was either really expensive or the places that I had to go to get it were dangerous, like some forbidding little bar or some strange, unappealing motel or housing project or what have you. But these guys made it easy. That's when it just went off the rails for a lot of these guys. So it made it easy in several ways. First of all, they made it cheaper. They would give you free dope from time to time to keep you using. And, all it was, was a phone call away. I remember I talked to one guy who had no legs. He had, because of his long addiction he had one day frozen, almost frozen to death in a storm, had lost his legs. And so, before these guys showed up, he had prosthetics: he had to hobble around downtown Portland 3 times a day to get his dope. And he didn't know what kind of quality it was going to be; people would rob him occasionally. It was just a torment. 'These guys show up and it's magnificent: these guys, they are a phone call away; I don't have to walk out of my motel to go hobble downtown Portland. They are cheap and frequently they give me free dope; they are clean; they are not going to rob me; they are nice guys; they are polite.' On and on like this. 'And it was almost like as if I'd died and gone to heaven: these guys were the best dealers I've ever seen. They gave me free dope; I could con them out of free dope.' Etc. And so his use kind of went off the rails. The convenience, the access to easy availability and cheap supply is what really, really pushed people over the edge a lot of times.
Russ Roberts: And of course as you mention in the book, none of these drivers, who are typically young kids, young men from this one town, they're not using. They are not--they don't sell to black people. They are afraid of them, for whatever reason--they are racist. They only sell to white people. Do they ever sell to fellow Mexicans? Because they need a Mexican community to hide among?
Sam Quinones: No. No. No--
Russ Roberts: And why not?
Sam Quinones: First of all, in the Mexican community, the level of heroin addiction is microscopically small. I don't know too many. Now, the Mexican-American community is a little bit different. But even so, this is a white person's problem all across the country. The pill problem, opiate addiction problem is really white people. No, they are a rare breed in the heroin world, the heroin retailer world, because most of the time, up to then--and I've had many cops in different cities tell me this--your typical heroin dealer was an addict. He was stationary: he was in a house; he was in a bar or a motel or someplace. And he was very easy to arrest and very easy to investigate. The only problem was back then no one bothered because it was such a small problem. These guys come along and they don't use. They are in and out; they are very quick; they are not hanging out; they are not partying; they are not causing a ruckus; they are not calling attention to themselves. And they don't hang out in one place. They don't have a bar or a house or something like that where they sell their dope.
17:10
Russ Roberts: So, as you point out, there's a poignance, an incredible poignance, to the fact that it's culturally repugnant to these folks to be a user. The idea that they are helping--often children, high schoolers and teenagers--get heroin is repugnant to them, because they would never want their own children, of course, to be doing this. And yet they come anyway, because it's very lucrative. And they come for very short periods of time. So, talk about the motivation of the young men who come from this one town--their cultural aspirations, their alternatives, a little bit about what life feels like in the town. Because it's incredible.
Sam Quinones: Yeah. Very interesting stuff. That's what I--I knew most about that when I started this book. They come from an area--a lot of these folks--immigrants in general, when they come to the United States, they are not the poorest of the poor. They are people who have--they are kind of working class folks; they have some resources, some assets but not a lot. And all around them they are seeing people who are doing better by going north. In the immigrants' case, work as landscapers; say, in this case,
'You guys come north and sell heroin.' But when these guys come back home, the guys who have gone north, they set a new standard for achievement: That, in order to be seen as having overcome poverty, you now need to be building yourself a house. For immigrants--Mexican immigrants--all across Mexico, they build houses. Hundreds of thousands of houses, maybe millions of houses, all across Mexico, because of that. And that becomes the norm, the standard by which you are judged, because you are not interested in becoming American. You are not interested in doing anything more than going home and showing the people who humiliated you when you were young that, 'This is what I'm really capable of. This house that I'm building is what I'm really capable of.' Now, that's the immigrants' impulse all across Mexico, I would say--I've studied this many years, wrote two books about it. I think this is a very, very important impulse. When it comes to drug trafficking, the impulse is the same; it's just that the risks and the rewards are many times greater. And so, you go north to sell dope, and you come home, and you build a house that might take a regular 9 years to build--you do that in 9 months, because you have the wherewithal, you have the capital. You don't have to build room by room, one room a year. You build it all in 9 months, and you build nice things like wrought iron and automatic garage door openers. And that kind of thing. What that does then is set the standard, set the bar very, very high for the other kids who are still poor in your town, are still kind of scuffling and wanting something--who no girl will talk to, who is not respected: their dad is an alcoholic, their dad is just a scuffling sugar cane farmer. These guys now have to reach this level, not the level of a house that it takes 9 years to build but one that it takes 9 months to build. And a lot of these guys have available to them only the most dead-end work in Mexico--sugar cane farming, bakery work, butcher, construction, avocado farming, etc. These things lead nowhere in Mexico. And they are not viewed as jobs that people really love to do. So, these guys all became--basically, two generations of this town, I think, became heroin traffickers up in the United States. And they all then went back home. They all brought their money back home. They all built houses--not lavish mansions. We are talking about middle-class houses. This is a system deterring you, transforming you from making you a poor person into a middle-class person, not into some drug kingpin. And everybody then, they would come home and they would be the kings for 6 weeks or 2 months or whatever. It wasn't all the girls then wanted to talk to them; and they could buy a good used truck; and they could build a house, a small house in 9 months instead of 9 years. And this became kind of what drove these kids forward. And then, also, once--the other thing, amazing to me, I thought, so fascinating--was that once they'd already done this--they'd done this once--they'd come back. They, too, would get addicted. Except it was not to the drug. It's to the feeling of coming home a king. Coming home a man of respect. Coming home a man with a trunkful of Levi's 501 Jeans and passing them out among your nephews; and your brothers-in-law, what have you. That was their drug. And so they'd spend their money and they'd be like a junkie without any dope and they'd have to go back to the United States to earn more money to come back and be the king for 6 weeks again. It was a fascinating peek into what really drives people. A lot of it is really psychology and aspiration.
22:06
Russ Roberts: And these are young--young men, typically. And a puzzle I had reading it--so, the profits--at one point you mention it takes about $2000 of time and equipment to cook a kilo of black tar heroin; about $50,000 to maintain the apartment and the car for the people and pay the drivers. So, for the person who is the distributor to the driver, sort of manager of the town of a certain number of drivers, there's $150,000 roughly of revenue.
Sam Quinones: Mmmhmm.
Russ Roberts: So there's a huge profit. It's $52,000 in costs; about $100,000 in profit. So, normally competition will drive that down. Of course, if it's dangerous, it doesn't drive it down very far. But I'm wondering why other towns didn't compete?
Sam Quinones: That's a very good question. Yeah. I'm not sure--
Russ Roberts: Is it just the technology of cooking it? Is it what they figured out that no one else has figured out?
Sam Quinones: No. That's more like a folk craft. You can cook black tar heroin from opium, the opium goo that you harvest from the opium poppy, and cook it into black tar heroin. I've seen film of this. The DEA actually has a confiscated film that I have in which a guy is cooking as if it were a barbecue. It's like a big barbecue grill and he's got a couple of pots going. And, no, it's not hard at all. I'm not sure exactly. In those areas, a lot of people were already going north to work. This is an area of very heavy immigration of the United States. They [?] were already involved in other jobs. Heroin is viewed, again, get back to kind of the way it's viewed in Mexico, is that the lowlife, most low-life, scuzziest, back-alley drug. And so getting involved in that is--you know. And it does take, I think, a fair amount of knowledge--a kind of breadth of knowledge that is developed over many years: trial and error. There is no book. They didn't use a book to figure out this system. It's: 'When it will get you arrested, let's not do that any more.' And, 'Let's try something else.' You know. I mean, it was--so, I'm not sure I know. I do know, though, that at a certain point, what started with a few families had to expand to many, many other families. So, for the first 15, 20 years of the life of this thing, a lot of these guys, there was the same last names: [? Hernandez, Tarjeta, Garcia-Langarica, sp?], a few others [? Diaz-?]. These kinds of last names. And they all were kind of connected and they all were related to each other. Sanchez family was a big one. But then they had--the DEA first figured these guys out in late 1999 and 2000. And they held the first big, nationwide bust. It was the first time in fact, that when they busted these guys, in I think in a operation called Tar Pit, it was the first time that the DEA and the FBI (Federal Bureau of Investigation) had actually worked together on a, and found a drug ring that went, literally, coast to coast, from North Carolina to Reno and Los Angeles and Phoenix, etc. And they arrested--I can't remember now as I talk to you, maybe 200 people. And with that, the families that ran those crews had to find more labor. A lot of those people went to prison, Federal prison, some for significant sentences--10, 15 years. So, what they began to do was expand to new families, families that had never been involved. And at 2000, the year 2000, just as the United States was developing a very healthy appetite for opiates of all kinds, they have to now expand throughout--so it's not just police go in a few of the little villages around there--they sometimes have to take labor from towns in other counties and people that they know, and I [?] a few of those as well. But it happened because their labor source, their labor supply, was in one fell swoop sent to prison. And so they needed to kind of fill the ranks with new folks.
Russ Roberts: And you went to Xalisco under cover, pretending you were not a journalist.
Sam Quinones: Right. First time I've ever done that, by the way. Any time people asked me, I'd say, 'I'm a journalist'--except for there.
Russ Roberts: You were scared.
Sam Quinones: I was not going to do that there.
Russ Roberts: Reasonably. So, you went to Xalisco. You've talked to these drivers--I think. You've talked to users. It's an incredible bit of reporting. And that's half the book. That would make a fantastic book. But it just gets more interesting, because there's an intersection with the opioid problem.
26:45
Russ Roberts: So, let's switch gears. Let's talk about painkillers. How did painkillers become a problem? It seems like there was this great new set of painkillers out, oxycontin and others. Why did they end up getting misused and abused?
Sam Quinones: Yeah. That was the--I backed into this story. Because of my background in Mexico, I really focused first on the heroin traffickers. But then, of course, I was left with the question: Why is it that they have so much new demand? Because they were now, by then, by the time I doing it, they were now in Ohio, West Virginia, places like that. And so that got me on to this other story that was really the first story, a really far larger story. And that begins, really, in the 1980s as well, about the same time, when pain management is just beginning to be kind of a new discipline within medicine that you study, and a whole group of pain specialists began to form a collective consciousness and believe that we were not treating pain correctly--that there were these pills, opiate painkillers out there, and doctors all across the country were unwilling to use these, and that this was not a reasonable proposition. That these pills ought to be far more liberally used. And at first they made the argument, 'We need to use these for hospice care folks, people dying of cancer, whatnot, in order to improve their last months on earth. What does it matter if they are addicted to these pills? Who cares if they are addicted to these pills if they also live the last 3 months of their lives pain-free?' And that made a lot of sense. That was a very logical argument: that folks would die in utter pain because doctors were afraid they would be addicted. But these folks made a different argument. They, however, kept pushing; and that's why we're here today. They didn't stop with just hospice care. They began to make the argument that virtually all of these pills, 'We now know--science now knows--that, you know, 5000 years of experience with the opium poppy be damned, we now know that these pills are virtually non-addictive when used to treat pain.' And they began to push. They were joined in this after a while by certain pharmaceutical companies who were producing some of these pills, main one being Purdue Pharma, which makes the pill Oxycontin. And they took up the call of these guys. I had one doctor say, 'If it hadn't been for the pain specialists, the pharmaceutical companies would have had nobody to footnote, to use to say this is why we're doing these, we're producing these pills.' But had it not been for the pharmaceutical companies, these pain specialists would have been without a megaphone. And so the combination of those two together, particularly as the 1990s progressed, becomes very, very potent. They begin to argue that we are a country in pain; virtually non-addictive now when used to treat pain to revolutionize our treatment of pain. And then, the game-changer comes with oxycontin. Oxycontin was a game-changer for a couple of reasons. The main one was that it was promoted by Purdue Pharma almost the way you would promote an over-the-counter medicine to doctors, with lots of giveaways and discounts--very much, as I got into my research, very much reminiscent of the come-ons and discounts that the Xalisco Boys would use to sell their heroin to their customers. And so a lot of these kinds of come-ons and this kind of thing; and they had a CD (Compact Disc) they gave away called "Swing in the Right Direction with Oxycontin." It was a bunch of swing band tunes; it was this kind of a new approach to marketing a drug. But it was an opiate--highly addictive; but they were using the idea that these drugs were virtually non-addictive, which was gaining credence in medicine. They were helped also by medical establishments--JCAHO (Joint Commission on Accreditation of Healthcare Organizations) that accredits hospitals came up with the idea that now doctors should use pain, should consider pain to be the 5th vital sign. So, they used to treat it just like you used to treat pulse or that kind of thing. But all these things should be treated the same and therefore pain is something you should always treating. There was a patient evaluation. So, there was this whole culture around the idea that we were, first, a country in pain; and what's more, that we were not treating it properly; and finally, that we had the tools but we had just been afraid to use them. And that was these opiate painkillers; and of the new one was oxycontin.
31:45
Russ Roberts: And as you point out, millions of people, who were in horrible pain weren't any more. So that was the good side. The bad side was the promised non-addictive aspect of oxycontin, which was the slow-release part--the idea that oxycontin was continuous was supposed to dampen the addictive part. Two things happened. One, people figured out a way to get around that by sucking off the coating that slowed the release; or hitting it with a hammer. So that was problem Number One. Problem Number Two is--I think; correct me if I'm wrong--that there were people who got addicted anyway, even though it was slow-release.
Sam Quinones: Yes. Right. They were following doctors' orders and they would still get addicted. And part of the problem, too, was that along with the idea that these pills were no longer addictive when used to treat pain, came the corollary which was then that there was no limit on dose. So, you began to see all across the country doctors prescribing enormous quantities of these pills for patients to take home with them after acute surgery, for acute pain after surgery. Now, this is pain that is probably going to last you, oh, no more than 3-5 days. If it lasts more than 5 days there's something else wrong. But, they would prescribe 30 days' worth of Vicodin or Oxycontin--these are common--Vicodin is another common opiate painkiller. And so what happened is--and then--and this was happening all across the country--an enormous new supply of opiates was created across the country; and a fair amount of that, a good amount of that leaked out into the black market. I believe this--when I was in Mexico, I believed that all drug stories were demand-driven, and that drug scourges were created by demand for those drugs. Now, when I did this book, this changed my mind, honestly: I came to think that really most drug problems begin because of excess supply--easy, cheap availability of a drug. And that's exactly what happened here. We have a new, a massive new supply of opiate painkillers from coast to coast, all across the country, because it's doctors who buy in to this idea. A couple of generations of doctors buy into the idea that they now need to very aggressively prescribe these things to treat our pain. And some are pushed or pressured. Legally you have to do this: If you don't treat pain, you can be sued. Some, it's insurance pressures; if we don't push people through our clinic we won't be able to reimburse enough to keep the lights on. But, whatever the case, doctors all across the country come to this idea that they need to do this. And that is what creates a massive and continuous new supply of opiate painkillers for the last 20 years, from coast to coast.
Russ Roberts: So, a couple of important footnotes. This same molecule really is heroin, correct? All of these are just variations--
Sam Quinones: All of these drugs are derived from the opium goo, the opium poppy, the goo that the opium poppy produces. So they all have molecularly--their molecular structure is more or less the same. They do a very good job of killing pain and they are extraordinarily addictive; and they have what--when you get off of them, they cause withdrawals. They have the same effect on the brain chemistry, no matter whether it's hydrocodone, oxycodone, heroin. There's some differences but by and large they all come from the same poppy. They are derived from the opium poppy.
Russ Roberts: The idea, which sounds reasonable, was that if you are in pain, the drug merely covers the pain and doesn't produce euphoria; if you continue to take the drug after the pain, then you can get addicted. But it turned out, of course, that we really don't understand why people get addicted in the first place. So, pain is not sufficient to avoid addiction to these drugs, evidently.
Sam Quinones: It is for some people. And for others it isn't. This is the problem. We applied the fire hose approach: You just blast everybody with opiates. And for some, that's fine; and a lot of our listeners they are now going, 'Yeah, I didn't have any problem.' And it's probably true. But there are an awful lot of people who do. And it's figuring out who is who beforehand that's the tricky question. Like, 'Is this a person who ought to get this much?' And doctors were not doing that. A lot of doctors didn't have time to do that. Time is the crucial thing that we have lost in modern American medicine. You do not have time as a primary care doc in most parts of America to sit down and ask a patient all the questions that really will allow you to come to a really clear idea of whether or not this person should get this quantity; and then, if that person should get that quantity over a period of time. They have shown, I think--there are studies that show that there is a very high incidence, risk of addiction, if you are given these drugs, exposed to these drugs no matter who you are, over--I believe it's 90 days. You get 100 milligrams a day, more than 90 days, something like that, I don't have it in front of me right now--but the risk of addiction is very, very high no matter who you are. But the problem is, we apply the fire hose approach. This is a very nuanced problem. Pain is a very nuanced issue, and you've got to spend time. It's individual. Every person is different. And when you try to apply a fire hose to everybody, things just don't go well.
Russ Roberts: So, just a couple of data points from Wikipedia, which you can--I think are consistent with the ones you mention in the book. It says
In the United States, more than 12 million people use opioid drugs recreationally. In 2010, 16,652 deaths were related to opioid overdose....
In 2007, about 42,800 emergency room visits occurred due to "episodes" involving oxycodone.
So, it's a serious problem. And in particular, particularly tragic, young people in particular geographic areas where usage, access was much easier, just thousands of lives were ruined. And eventually--
Sam Quinones: And continued to be--
Russ Roberts: And continued to be--
Sam Quinones: By the way, this is something--you know, the CDC (Center for Disease Control) just put out information that shows that we have now more heroin-related deaths than gun homicides, in 2015 as a country. That's a spectacularly--
Russ Roberts: Tragic--
Sam Quinones: It's a tragic thing. It's just blows my mind.
38:38
Russ Roberts: So, talk about how the heroin distribution started in Iraq with the opioid distribution.
Sam Quinones: Sure. The reason I write about the Xalisco Boys, as I call them--these guys who developed this system for selling heroin a lot like pizza delivery, is not because they are the only heroin traffickers from Mexico. Nor is it really that they are the only black tar traffickers from Mexico. The reason I wrote about them was--two reasons. One was that, really, they developed this kind of new way of trafficking that was based on marketing now. Very heavy on marketing. Almost no violence. No violence at all. 'Violence, bad; can get us a lot of prison years. We forget about that.' But the other reason is because they--as they expanded, as they were going through this kind of capitalist expansion mode, through the 1990s, they jumped the Mississippi River. They are the first ones to bring black tar heroin east of the Mississippi River in the history of that drug--according to the DEA. They are the first ones to jump the Mississippi River. And they do this--one guy in the book does this in 1998. Now, that's a crucial year because it's just at that moment when this pain, this revolution in pain management is really taking hold, and when, in that area of Columbus, Ohio, to the north--Cincinnati to the west, West Virginia, eastern Kentucky, that very, very roughly-drawn area--that is the area where Purdue Pharma is first very, very aggressively promoting and marketing Oxycontin. And you are finding now lots of people beginning to get addicted. And all of a sudden they land in an area--pure coincidence; there's no conspiracy here--they just happen to land in an area where for the first time they find a huge number, a growing population of addicts. And then a growing demand. And so, they are the first ones to recognize and then systematically exploit the coming market for heroin that this massive, kind of fire hose approach to prescribing opiate pain pills implies. And they just hang out in Columbus, Ohio. And this guy tells me, 'At first it was amazing. I was just doing this business; I had two kids up there driving for me; and I was lying to all my friends back home. I was saying, no, I'm in New York City; or I was telling them all kinds of lies about where I was. Last thing I wanted them to know was that I was in Columbus, Ohio. But then these kids go back home; they come back home with lots of money for the parties; they are showing off from the girls. And pretty soon everybody gets the idea of Columbus is the place to go.' And within a year or two, I think about two years of his first arrival in the summer of 1998, you know, Columbus is beginning to get one crew after another. And I think lately--it comes and goes--but I think they've got 10 or 12 crews working from this one town in Columbus, or had, the last I heard, anyway. And they begin to bring--you know, it's a fascinating story. Oxycontin is a game-changer for another reason, not just how it's marketed. But, because before Oxycontin, people would mess around with low-dose Vicodin, Percocet. But those have acetaminophen in them. They have Tylenol in them. If you develop a large addiction to those, you will destroy your internal organs. Oxycontin has none of that. So it takes people up to very, very large addiction levels, daily addiction levels, so you have to be doing 100, 200, 300 milligrams a day of these pills--that's $1 dollar a milligram on the street. So, it's 100, 200, 300 milligrams a day. Well, you can't sustain that. There's no way you can continue with that. So you begin to look for something very cheap and just as potent. And cheap Mexican heroin fills that bill perfectly. And their heroin fills that bill absolutely. And it's easy to get. And it's available. And they'll give you free come-ons and discounts, etc. And so it's that kind of encounter, between the heavy marketing of pain pills and Purdue Pharma, and the pill mills were beginning in that area as well; and then the encounter of these heroin traffickers with this new system and this very cheap, very potent dope that creates the first examples of what we're now seeing all across the country, almost in every state of the union. Which is: people getting addicted first to pills, and then transitioning to very cheap Mexican heroin. It's not always the Xalisco Boys doing the selling in every state. But that's where you first see it. That's Ground Zero, that whole region, south of Columbus, Ohio.
43:26
Russ Roberts: So, there's a lot of things to talk about here, but I just want to make sure I get this question in, because it's haunted me, reading your book. Which is: I have very limited experience with opiates of any kind. And so I can't really--I once had a root canal, and I had codeine afterwards, with Tylenol. And it was really pleasant; I really--it was blissful. The pain went away. I slept incredibly well. That's really about it for me. So I'm really not a very good data point. But after I read your book, I did find myself--because there's so many teenagers and young people whose lives are ruined or who died tragically, in this book. And I'm going to tell listeners: It's not a sensationalist book at all. One of the great reasons it's such an effective book is that it's not sensational. Your imagination does a lot of the work. And it's really a--it's a police kind of book--what's the right word? It's a--I can't remember the word.
Sam Quinones: Well, I try not to use adjectives.
Russ Roberts: Yah. Exactly. It's a procedural book. So, I found myself calling my kids--off at college and telling them, 'Try to avoid these drugs if you need them.' And my question is-- 'And certainly stay away from, if somebody offers you a balloon of black tar heroin for free, don't take it.' Which is obviously pretty good advice. But I found myself wondering, if they had surgery of some kind, and you give many examples of this where some kid in the football team gets shoulder separation and he gets prescribed drugs by a doctor to take care of the pain--and he ends up dead. And so, would you counsel your children? Would you, yourself take these opioids in the aftermath of surgery?
Sam Quinones: Well, look. First of all, it's incumbent upon doctors to know the person. And know--and so that is a big thing. And parents, for them to know their kids. With regard to athletics, you are absolutely right. [More to come, 45:23]